PMDC National Licensing Examination Obstetrics and Gynaecology Syllabus

How is gestational hypertension defined?

New-onset blood pressure of 140/90 mmHg or higher after 20 weeks of gestation, without proteinuria or features of pre-eclampsia, in a previously normotensive woman.

What are the diagnostic criteria for pre-eclampsia?

New-onset hypertension (BP 140/90 or higher) after 20 weeks PLUS proteinuria (300 mg/24h or protein:creatinine ratio 30 mg/mmol), OR hypertension with end-organ dysfunction (renal, hepatic, neurological, haematological) or fetal growth restriction.

What features define severe pre-eclampsia?

BP 160/110 or higher, severe headache, visual disturbance, epigastric/RUQ pain, papilloedema, clonus, liver tenderness, platelets <100, abnormal LFTs, or HELLP syndrome.

What does HELLP syndrome stand for?

Hemolysis, Elevated Liver enzymes, and Low Platelets - a severe variant of pre-eclampsia.

What is eclampsia and what is the drug of choice for treating and preventing seizures?

Eclampsia is the occurrence of generalized seizures in a woman with pre-eclampsia. Magnesium sulfate is the drug of choice for treatment and prevention of eclamptic seizures.

What are the signs of magnesium sulfate toxicity and the antidote?

Loss of deep tendon reflexes (earliest), respiratory depression, then cardiac arrest. Monitor reflexes, respiratory rate, and urine output. Antidote is intravenous calcium gluconate.

What antihypertensives are considered safe and commonly used in pregnancy, and which are contraindicated?

Safe: labetalol, methyldopa, nifedipine, hydralazine. Contraindicated: ACE inhibitors and ARBs (fetal renal damage), and atenolol (growth restriction).

What aspirin prophylaxis is recommended for women at high risk of pre-eclampsia?

Low-dose aspirin (75-150 mg daily) started from about 12 weeks until delivery.

How is gestational diabetes mellitus (GDM) defined?

Carbohydrate intolerance with onset or first recognition during pregnancy, due to pregnancy-induced insulin resistance, in a woman not previously diabetic.

What are common WHO/IADPSG OGTT thresholds for diagnosing gestational diabetes?

Fasting glucose 5.1 mmol/L or higher, 1-hour 10.0 mmol/L or higher, or 2-hour 8.5 mmol/L or higher (after 75 g glucose). One abnormal value is sufficient.

What is the first-line management of gestational diabetes, and what medications are used if it fails?

First-line: diet and exercise. If glycaemic targets are not met, metformin and/or insulin are used. Insulin is the mainstay when needed; it does not cross the placenta.

What are the major fetal/neonatal complications of poorly controlled gestational diabetes?

Macrosomia, shoulder dystocia, polyhydramnios, neonatal hypoglycaemia, respiratory distress syndrome, and increased risk of stillbirth and congenital anomalies (the latter mainly with pre-existing diabetes).

What follow-up is advised for a woman after a pregnancy complicated by gestational diabetes?

A postpartum OGTT (usually at 6-12 weeks) to exclude persistent diabetes, and lifelong screening as she has greatly increased lifetime risk of type 2 diabetes.

How is antepartum hemorrhage (APH) defined?

Bleeding from the genital tract after 24 weeks (or after the age of fetal viability) and before delivery of the baby.

What is placenta praevia and how does it classically present?

Placenta implanted wholly or partially in the lower uterine segment, over or near the internal cervical os. Classic presentation is painless, recurrent, bright-red vaginal bleeding; the uterus is soft and non-tender.

What is placental abruption and how does it classically present?

Premature separation of a normally sited placenta. Classic presentation is painful vaginal bleeding with a tense, tender ('woody' hard) uterus; bleeding may be revealed or concealed. Risk factors include hypertension, trauma, and smoking.

Why is a digital vaginal examination contraindicated in suspected placenta praevia?

It can provoke catastrophic haemorrhage. The placenta location must first be confirmed by ultrasound; a speculum may be used cautiously but digital examination is avoided until praevia is excluded.

What is vasa praevia and why is it dangerous?

Fetal vessels run through the membranes over the cervical os, unsupported by placenta or cord. On membrane rupture they tear, causing fetal (not maternal) haemorrhage and rapid fetal exsanguination - a fetal emergency.

How is obstructed labor defined?

Failure of the presenting part to descend despite adequate uterine contractions, due to mechanical obstruction (cephalopelvic disproportion, malpresentation, fetal/maternal abnormality).

What is a pathological (Bandl's) retraction ring and what does it signify?

A visible/palpable ridge between the upper and lower uterine segments rising toward the umbilicus; it is a warning sign of obstructed labor and impending uterine rupture.

What are the classic signs of impending uterine rupture in obstructed labor?

Bandl's ring, severe continuous pain, maternal tachycardia, haematuria, a tense tender lower segment, and fetal distress. Sudden cessation of contractions with collapse signals rupture.

What is an obstetric (vesicovaginal) fistula and how does prolonged obstructed labor cause it?

An abnormal communication between bladder and vagina causing continuous urinary incontinence. Prolonged pressure of the fetal head on the bladder against the pubic symphysis causes tissue ischaemia and necrosis.

What is an ectopic pregnancy and what is the most common site?

Implantation of a pregnancy outside the uterine cavity. The most common site is the fallopian tube, specifically the ampulla.

What is the classic clinical triad of a ruptured ectopic pregnancy?

Amenorrhoea (missed period), abdominal/pelvic pain, and vaginal bleeding - often with signs of shock and shoulder-tip pain if there is intraperitoneal bleeding.

What are the major risk factors for ectopic pregnancy?

Previous ectopic, pelvic inflammatory disease/tubal damage, previous tubal surgery, endometriosis, IUCD in situ, assisted reproduction, and smoking.

What medical treatment can be used for a small, unruptured, stable ectopic pregnancy?

Methotrexate (a folate-antagonist that halts trophoblast proliferation), in carefully selected stable patients with low beta-hCG and no fetal cardiac activity, followed by serial hCG monitoring.

How is abnormal uterine bleeding classified using the FIGO PALM-COEIN system?

Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia. Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified.

What investigation is mandatory in a woman over 45 (or younger with risk factors) presenting with abnormal uterine bleeding?

Endometrial biopsy/sampling (with transvaginal ultrasound) to exclude endometrial hyperplasia or carcinoma.

What is pelvic inflammatory disease (PID) and which organisms most commonly cause it?

Ascending infection of the upper female genital tract (endometritis, salpingitis, oophoritis, peritonitis). Most common organisms are Chlamydia trachomatis and Neisseria gonorrhoeae.

What is Fitz-Hugh-Curtis syndrome?

Perihepatitis (inflammation of the liver capsule with characteristic 'violin-string' adhesions) complicating pelvic inflammatory disease, causing right upper quadrant pain.

What is the most common benign uterine tumor, and which type of fibroid most commonly causes heavy menstrual bleeding?

Uterine leiomyoma (fibroid) is the most common benign uterine tumor. Submucosal fibroids are most associated with heavy menstrual bleeding; they are estrogen-dependent and tend to regress after menopause.